Healthcare Provider Details

I. General information

NPI: 1801480629
Provider Name (Legal Business Name): KYRA LEE KEUBEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 12/10/2023
Certification Date: 12/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 N MILWAUKEE AVE STE 202
CHICAGO IL
60630-2156
US

IV. Provider business mailing address

3452 N AVERS AVE APT 3R
CHICAGO IL
60618-5214
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-2898
  • Fax:
Mailing address:
  • Phone: 630-740-7074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.022552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: